Provider Demographics
NPI:1306928551
Name:AGOSTINELLI, THERESA A (PNP)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:A
Last Name:AGOSTINELLI
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 ELMGROVE ROAD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-6236
Mailing Address - Country:US
Mailing Address - Phone:585-426-4100
Mailing Address - Fax:585-426-3701
Practice Address - Street 1:900 ELMGROVE ROAD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-6236
Practice Address - Country:US
Practice Address - Phone:585-426-4100
Practice Address - Fax:585-426-3701
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3810951363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01725OtherBLUE SHIELD OF ROCHESTER
NY01903277Medicaid
4129731OtherMVP
4129731OtherUPSTATE DHP
RC60164923OtherPOMCO
4334391OtherAETNA
Y028938OtherTRICARE REGION I
4334391OtherUS HEALTHCARE
NYNP0023OtherPREFERRED CARE
P010164923OtherEXCELLUS
P010164923OtherBLUE CHOICE